FINANCIAL AID CONSIDERATIONS
Finally, before you leave medical school you will be required to have an exit interview with your financial-aid advisor. This will be an opportunity to review your total loan package, the repayment requirements, and your options for deferment or forbearance. Federal law requires a financial-aid advisor to have this meeting with you to ensure that you are aware of your obligations regarding your loans. Spend some time prior to this meeting organizing your files and bringing yourself up-to-date on your financial-aid package. If you have additional credit card or other outstanding debt, gather these records and try to formulate a plan for repaying or managing this debt as well.
When you meet with your financial-aid advisor, review your complete financial picture and discuss how your loans fit into this. Find out if there are any unique loans in your package that mature at different times or have unusual repayment requirements. It is absolutely critical that you be organized and on top of your loans prior to leaving medical school. The next chapter will delve more deeply into the key loan-management tasks you should accomplish before starting work. Once you start your internship, you want these things to be on autopilot so you don’t have to spend your precious free time stressing about the details.
PART SIX
The Transition to Residency and Life as a Physician
CHAPTER 27
Making the Leap
The trouble with getting a life is making the payments.
—UNKNOWN
GRADUATION IS FAST becoming a hazy memory, and the celebratory headache is finally starting to fade. You now proudly list M.D. or D.O. after your name. Since med schools typically graduate in mid-to-late May but your residency won’t start until the last week of June, you find yourself staring at a few precious weeks to pack up shop and make a new life for yourself as an intern. Just like the transition to medical school, take advantage of this small interlude and organize yourself in preparation for the onslaught—you’ll thank yourself later.
SETTING UP SHOP
Start with the basics—make yourself a home and headquarters. If you’re staying in the same town or area, you may not need to move at all. Then again, new digs, with or without roommates, may be a refreshing change. Residents don’t make much, but you may find you can afford a step up in housing on your new salary.
If you’re moving to a new area, it’ll be worth rereading the sections of this book on finding a home in a new area. The same considerations will apply. The primary principles for all that you do should again be safety, convenience, and simplicity. Your schedule will be so hectic and your fatigue often so great that having a long commute or complicated living situation is to be avoided at all costs.
ORGANIZING YOUR LIFE
Get your new life up and running as quickly as possible. Find an apartment or house near the hospital that is simple, safe, and lowmaintenance. Get your bank account set up and activate direct deposit for your paycheck. Establish online banking so you can pay your bills at odd hours and on Sundays; or, better still, set up automatic payments for as many bills as possible so you don’t even have to worry about them. Be sure to make allowances in your budget for time off, time away, and time to work out and remain in shape.
Now more than ever, balance is key.
MANAGING YOUR LOANS
Your financial-aid exit interview should have made clear that qualifying for and accumulating debt is easy—but repayment is a bitch. Thankfully there are ways you can put off this problem until you are out of training and have a more substantial income.
As noted in chapter 11, your loan package will come in two major forms—subsidized and unsubsidized loans. None of your loans will require repayment prior to graduation, but your unsubsidized loans do begin to accrue interest. You’ve already watched these loan balances balloon with each passing statement.
Now is the time to be proactive in managing this debt.
If you’re interested in any of the repayment options such as the National Health Service Corps or the military, you can still enroll to immediately reduce or even eliminate your debt burden. But even if these options aren’t for you, read on as we discuss strategies for managing your loans.
The first step, as always, is to get everything in order. Hopefully your loan files are still well organized from your discussions with your financial-aid advisor at your exit interview. If you haven’t already, make yourself a spreadsheet of all the loans in your financialaid package, their total amount, and the date they go into active repayment. Make sure all the lenders have a current address for you once you get established. The last thing you want is creditors hunting you down because a lender can’t find you and puts you in default on a loan you didn’t know was due. If you’re like most students, the bulk of your package will be federal loans, with a few Perkins or private loans added in. You may want to scrutinize these nonfederal loans first. If they’re for smaller dollar amounts and you can afford to do it, you may want to consider paying them off at this point. This will simplify your mix of loans and make the next steps, consolidation and repayment, easier.
Most federal loans go into repayment six months after you cease being a full-time student. Unfortunately, your graduate training in internship and residency does not qualify you as a student. Thus, you will be expected to start making payments on your student loans halfway through your internship. For most, this is not a tenable position, as a resident’s already small salary won’t stretch far to cover a hefty loan payment. That’s the bad news. The good news is there are key ways you can both reduce and defer these payments.
Your first and most critical action should be to consolidate the many loans in your package into a single jumbo loan. This will allow you to do three things: first, you will have to make only a single loan payment each month to the consolidator, which simplifies your paperwork and accounting; second, the consolidated loan will be locked in at a single interest rate, allowing you to more accurately budget and plan; and finally, and most important, because the consolidated lender will have a much larger loan they will offer you a much more favorable rate. This will save you tens of thousands of dollars over the life of the loan.
Do not fail to take this critical step.
There are many ways to consolidate your loan, and your mailbox will literally be inundated with offers. The federal government has its own consolidation program through the Direct Loans Servicing Agency (www.dlservicer.ed.gov) for consolidation of federal loans. If you have private loans and equity lines, you will need to consolidate these through a private lender. Several large private lending institutions like Sallie Mae and Washington Mutual also offer private consolidation packages. While their rates and terms are not as good as the federal consolidation service, they are still considerably better than your individual unconsolidated loans would be. In the end, you should shop around and identify the best offer with the lowest fixed rate—but be on the lookout for hidden consolidation fees and costs that might make an amazing offer too good to be true. Also note that the federal consolidation program has options that allow you to defer your loan payment further (this is discussed below). Some private lenders offer this, but some don’t, so investigate thoroughly before you commit.
Now that you’ve shed the tiny loans and consolidated the remainder into one low-interest megaloan, you’re ready to worry about the fact that you still can’t figure out how you’ll afford even the reduced monthly payments.
You have some options here as well.
There are two ways to avoid immediate repayment on federal loans. The first, and certainly the best financial option, will be to apply for economic hardship deferment. If you have prior student loans (i.e., from your undergraduate days) and you make below a set salary, you may qualify to defer payment on any of your loans interest free.
Wow.
You will have to reapply for economic hardship deferment every year to ensure that you qualify for the program.
If you don’t have prior student loans or o
therwise don’t qualify for economic hardship, you may instead elect to go into forbearance. Forbearance requires you to affirm to the government that you remain financially incapable of repaying your loans right now, and to pledge to assume payments as soon as you can. Your loans will continue to accrue interest, and, in fact, you’ll continue to get bills in the mail for your payments. But as long as you’re in forbearance, you won’t be required to repay a cent.
At the end of the forbearance period, you will resume payments on the full amount, including the interest you’ve accrued. This is a decidedly less ideal solution, but it at least buys you the time to get your training done and a real salary in place.
Finally, and as always, stay organized. Life’s about to get hectic again, so keep your files in order and stay on top of your loan responsibilities. These are big numbers with serious consequences, so make it a priority to stay on top of deadlines and keep yourself in the clear. You’ll rest easier knowing your loans are under control.
CHAPTER 28
Starting Out Strong in Residency
There is a certain relief in change, even though it be from bad to worse!
As I have often found in traveling in a stagecoach, that it is often a comfort
to shift one’s position, and be bruised in a new place.
—WASHINGTON IRVING
BY NOW YOU’VE been through this transition thing a number of times. You know it feels terrifying initially, but then you get your feet under you and you begin to realize you really can handle Orgo, or Anatomy, or the boards, or your first day on the wards, or . . . your first day of internship. There is no doubt that you are making a major transition from medical school to residency, but if you take it one step at a time everything will fall into place.
ORIENTATION
Your first day will be July 1. About a week or so prior to this, however, you will probably have orientation activities arranged by your new program. Most of these activities will be administrative tasks like getting your ID and new white coats, but there will be some social events with the other residents and your new classmates thrown in. You’ll probably also have some basic didactics to help you get on your feet. The didactics will focus on common conditions you will encounter and common problems that may arise on call and on the wards. The week will be a general blur, filled with new people, new places, and too much information to handle. Don’t worry. Absorb what you can and assume you’ll pick up the rest along the way.
YOUR FIRST DAY ON THE WARDS
Getting used to a new hospital is never easy. Then again, you’ve become a professional at reinventing yourself with every new rotation you encountered. Jumping into a new team with a new set of responsibilities will feel surprisingly familiar by this point. Plus, everyone around you will be going through exactly the same thing. Take your time, be honest about what you don’t know or don’t feel comfortable doing, and things will fall into place.
While the hospital environment will feel familiar, you may be struck by the degree to which your workload has changed. Your senior residents will quickly start piling on the patients, and before you know it, you’ll have a juggling act going. The first time your pager goes off, you’ll pretty much jump out of your skin. You’ll nervously dial the number and have to suppress the urge to say you’re a medical student returning a page. Chances are it will be some prosaic question that the nurse pretty much could have answered on his or her own. Nonetheless, you’ll jump to the task with pride, eager to make a strong first impression.
Then it will go off again.
And again.
Pretty soon you’ll start wondering how you’re going to get anything done with that thing attached to your hip. Just as you’re admitting your fourth patient of the day, you’ll get paged from the floor that someone’s blood pressure is 70 and they’re not breathing too well.
Uh-oh. Then you’ll get paged by your resident telling you there’s another admission coming in twenty minutes.
Then your attending will call to ask if you’ve finished the first admission and whether or not you’re ready to discuss the case.
And somewhere around then, you’ll feel a bead of perspiration run down your forehead and suddenly find it difficult to swallow. Don’t worry. You’ll get comfortable, get into the rhythm of your service, and get infinitely more efficient.
YOUR FIRST CALL NIGHT
The looming responsibility of call will first dawn on you at evening sign-out. Your team will gather and you’ll step through the patient list for the entire service, listening to the bullet-item highlights on each patient and anything that needs to be done overnight. “Mr. Harmon is recovering from a GI bleed. Keep his pressures below 140 systolic and check a hematocrit that has been ordered for midnight. Transfuse for anything less than 20 percent.”
“Uh, okay,” you say. “How do I check a timed lab? And how do I order a blood transfusion?”
In the meantime, you’re already at the next patient and the resident is expanding your already burgeoning to-do list. Just keep scribbling away and make yourself check boxes for each task you need to complete. You’ve got the rest of the night to track down results and keep everyone alive.
That first night will be a long and sleepless one. You’ll probably get several admissions that you’ll handle with your team, all the while being paged continuously from the floor. Your history and physical notes will be long and a little shaky. When you do finally lay your head down in the call room, your pager will go off.
A basic rule of call nights is: when in doubt, go see the patient in person. Answer the question after you’ve had a chance to look through the chart and get some perspective on the case. Let yourself build some experience before being cavalier about answering questions and ordering meds on patients you know relatively little about. If you have doubts or concerns, don’t feel awkward about calling your senior resident or attending. They’re expecting this. Better by far to speak up and ask a stupid question than to be proven a fool when you make a silent guess and put a patient in jeopardy.
Morning will come with agonizing slowness. As your team files in for morning sign-out, you’ll again step through your list, reporting on the events of the night for each patient.
Now you get to start a regular day and go right into prerounds, get your notes written, and then slow-walk rounds with the team. As fatigue overcomes you, you’ll find yourself leaning against doorways while you listen to other presentations, drifting into half sleep, only to be jarred awake periodically by a sudden pimping question.
At long last, rounds will end and you’ll sign out your patients to a fellow team member and get to go home. This will usually be around noon. When you get home, unplug your phone, turn off your pager, and crash into your own, peaceful, undisturbed bed for some muchneeded and much-deserved rest. Congrats! You survived your first call night.
Now get some sleep so you can do it all again tomorrow.
UNDERSTANDING ACADEMICS IN RESIDENCY
Unfortunately your dreams of putting the books up) on the shelf once and for all are just that—fantasies. Studying will be a persistent activity throughout your residency. True, it will come in different forms, but regular reading and didactic learning will be fundamental to your overall education in residency. While you may be employed by the hospital as a clinician, you’re still very much a student of medicine. You should be reading about the cases that you encounter, on a daily basis if possible.
Your lectures in residency will come in the form of weekly didactic conferences. Some programs have one or two hours a day; others block the lectures into a single day a week. The conferences will be led mostly by faculty members, and each hour will typically cover a different topic germane to your field of study. Some will be given by fellow residents, and, indeed, as you progress in your training you will be asked to prepare and deliver more and more of these. These are the same conferences you sat through as a medical student while on various rotations—only now, you’ll be a resident sharing the
hot seat for pimping questions. At least once a month you’ll probably have some sort of “Morbidity and Mortality” conference in which critical cases are dissected and the errors or opportunities for improvement discussed candidly. These can be painful, especially when a case you were involved with turned out badly, but this is also some of the most poignant learning you will ever do.
We all learn through our mistakes—and nowhere is this more humbling than in medicine.
Finally, you’ll probably meet monthly at a restaurant as a resident group for a “Journal Club.” You’ll have a few beers and discuss some articles from the literature.
You will also have an annual in-service exam that is meant to be a precursor to the specialty board exam you’ll take after you graduate from residency. To prepare for the in-service, and to get you on track for your boards, you should find a good board review book for your specialty and systematically work your way through it. It will seem painful to continue the drudgery of textbook reading, but incremental efforts throughout your years as a resident will pay big dividends in the end. Furthermore, staying abreast of your field will be a lifelong pursuit, so working now to instill good reading habits will serve you and your patients for years to come.
Med School Confidential Page 27